Company/Firm Name & ABC COMPANY Address Name of Owner Sr. No.

Pan Rahul dravid Place Name Father Name

Adddress Designation Address

1 aa

mumbai

bhushan

Mr. s.k.goyal

114,sec 5 delhi

120 sambhu nagar, mumbai Properitor Amount of Such Loan Date on which Amount given On Loan 1-Apr-11 2011

Financial Year 2012

Date of Credit of Interest 31-Mar-12

Amount Rate of of Interest Interest 15000 12

1180000

FORM NO. 15G

[ See rule 29C]

Declaration under sub-sections (1) and (1A) of section 197A of the Income-tax Act, 1961, to be made by an individual or a person (not being a company or a firm) claiming certain receipts without deduction of tax
bhushan, Pan Number aa I/We* *son/daughter/wife of Mr. s.k.goyal resident of 114,sec 5 delhi @ do hereby declare (name and address 1 *that I am a shareholder in of the company) and the shares in the said company, particulars of which are given in Schedule I below, stand in my name and are beneficially owned by me, and the dividends therefrom are not includible in the total income of any other person under sections 60 to 64 of the Income-tax Act, 1961; Or *#that the securities or sums, particulars of which are given in Schedule II or Schedule III or Schedule IV below, stand in *my/our name and beneficially belong to *me/us, and the *interest in respect of such securities or sums and/or income in respect of units is/are not includible in the total income of any other person under sections 60 to 64 of the Income-tax Act, 1961; Or *that the particulars of my account under the National Savings Scheme and the amount of withdrawal are as per the Schedule V below; 2 that *my/our present occupation is; 3 that the tax on *my/our estimated total income, including *the dividends from shares referred to in Schedule I below; and/or *#interest on securities, interest other than interest on securities and/or income in respect of units, referred to in Schedule II, Schedule III and/or Schedule IV below; and/or *the amount referred to in clause (a) of sub-section (2) of section 80CCA, mentioned in Schedule V below, computed in accordance with the provisions of the Income-tax Act, 1961, for the previous year ending on "31relevant to the assessment year will be nil; 4 that *my/our income from *dividend/interest on securities/interest other than "interest on other than interest on securities/units/amounts referred to in clause (a) of sub-section (2) of section 80CCA or the aggregate of such incomes, computed in accordance with the provisions of the Income-tax Act, relevant to the assessment year 1961, for the previous year ending on will not exceed the maximum amount which is not chargeable to income tax. 5 that *I/we have not been assessed to income-tax at any time in the past but I fall within the jurisdiction of the Chief Commissioner or Commissioner of Income Tax ____________________ Or that *I was/we were last assessed to income-tax for the assessment year by the Assessing Officer Circle/Ward/District and the permanet account number alloted to me is PAN aa 6 that I *am/am not resident in India within the meaning of section 6 of the Income Tax Act, 1961; 7 Particulars of the *shares of the company/securities/sums/account under the National Savings Scheme and the amount of withdrawal referred to in paragraph 1 above, in respect of which the declaration is being made, are as under:

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No. of shares

Class of shares and face value of each share

SCHEDULE I Total face Distinctive value of numbers of the shares shares SCHEDULE II Date(s) of Amount of securities securities

Date(s) on which the shares were acquired by the declarant

Description of securities

Number of securities

Date(s) on which the securities were acquired by the declarant

Name and address of the person to whom the sums are given on interest ABC COMPANY,120 sambhu nagar, mumbai Name and address of the Mutual Fund

Amount of such sums

SCHEDULE III Date on which sums were given on interest

Period for which such sums were given on interest

Rate of interest

1180000

1-Apr-11 SCHEDULE IV Class of units and face value of each unit

2011-2012

12%

Number of units

Distinctive number of units

Income in respect of units

Particulars of the Post Office where the account under the National Savings Scheme is maintained and the account number

SCHEDULE V Date on which the account was opened

The amount of withdrawal from the account

**Signature of the declarant Verification *I/We bhushan do hereby declare that to the best of *my/our knowledge and belief what is stated above is correct, complete and is truly stated. Verified today, the Place mumbai Signature of the declarant 31 st day of March, 2012

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Notes: 1 @ Give complete postal address. 2 The declaration should be furnished in duplicate. 3 *Delete whichever is not applicable 4 #Declaration in respect of these payments can be furnished by a person (Not being a company or a firm). 5 **Indicate the capacity in which the declaration is furnished on behalf of a Hindu Undevided family, association of persons, etc. 6 Before signing the verification, the declarant should satisfy himself that the information furnished in the declaration is true, correct and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecution under section 277 of the Income-tax Act, 1961, and on conviction be punishable PART II [FOR USE BY THE PERSON TO WHOM THE DECLARATION IS FURNISHED] 1 Name

2 3

and address of the person ABC COMPANY,120 sambhu nagar, mumbai responsible for paying the income, mentioned in paragraph 1 of the declaration Date on which the declaration was 31st March, 2012 furnished by the declarant Date of *declaration, distribution or payment of dividend / withdrawal from account number under the National Savings Scheme 01-04- 2011 to 31-03-2012 Period in respect of which *dividend has been declared / interest is being credited or paid / income in respect of units is being credited or paid Interest Rs. 15000/Amount of *dividend / interest or income in respect of units / withdrawal from National Savings Scheme Account 12% *Rate at which interest or income in respect of units, as the case may be, is credited/paid Forwarded to the Chief Commissioner or Commissioner of Income-tax

Place mumbai Date 31st March, 2012

Signature of the person responsible for paying the income referred to in Paragraph 1

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FORM NO. 15H [See rule 29C(1A)] Declaration under sub-section (1C) of section 197A of the Income-tax Act, 1961, to be made by an individual who is of the age of sixty-five years or more claiming certain receipts without deduction of tax
I, resident of @ do hereby declare-

*son/ daughter/ wife of

1. *that the shares/securities/sums, particulars of which are given in the Schedule below, stand in my name and are beneficially owned by me, and the dividend/interest in respect of such *securities/sums and/or income in respect of units is/are not includible in the total income of any other person under sections 60 to 64 of the Income-tax Act, 1961; OR *that the particulars of my account under the National Savings Scheme and the amount of withdrawal are as per the Schedule below: SCHEDULE
Description and details of investment Amount invested Date of *investment/opening of account Estimated income to be received

2 that my present occupation is ; 3. that I am of the age of years and am entitled to a deduction from the amount of income-tax on my total income referred to in section 88B; 4. that the tax on my estimated total income, including *income/incomes referred to in the Schedule below computed in accordance with the provisions of the Income-tax Act, 1961, for the previous year ending on relevant to the assessment year will be nil; 5. that I have not been assessed to income-tax at any time in the past but I fall within the jurisdiction of the Chief Commissioner of Income-tax or Commissioner of Income-tax OR that I was last assessed to income-tax for the assessment year by the Assessing Officer
Circle/Ward and the Permanent Account Number allotted to me is

6.

that I *am/am not resident in India within the meaning of section 6 of the Income-tax Act, 1961;

Signature of the declarant

Verification
I do hereby declare that to the best of my knowledge and belief what is stated above is correct, complete and is truly stated. Verified today, the day of

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Place

Signature of the declarant

Notes : 1. @ Give complete postal address. 2. The declaration should be furnished in duplicate. 3. *Delete whichever is not applicable. 4. Before signing the verification, the declarant should satisfy himself that the information furnished in the declaration is true, correct and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecution under section 277 of the Income-tax Act, 1961, and on conviction be punishable(i) in a case where tax sought to be evaded exceeds one lakh rupees, with rigorous imprisonment which shall not be less than six months but which may extend to seven years and with fine; (ii) in any other case, with rigorous imprisonment which shall not be less than three months but which may extend to three years and with fine.

PART II [FOR USE BY THE PERSON TO WHOM THE DECLARATION IS FURNISHED]

1. Name and address of the person responsible for paying the income, mentioned in paragraph 1 of the declaration 2. Date on which the declaration was furnished by the declarant 3. Date of *declaration, distribution or payment of dividend/withdrawal from account number under the National Savings Scheme. 4. Period in respect of which *dividend has been declared/interest is being credited or paid/income in respect of units is being credited or paid 5. Amount of *dividend/interest or income in respect of units/withdrawal from National Saving Scheme Account 6. *Rate at which interest or income in respect of units, as the case may be, is credited/paid Forwarded to the Chief Commissioner or Commissioner of Income-tax, from account number

Place Date

Signature of the person responsible for paying the income referred to in Paragraph 1

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